Oral Health Risk Assessment Tool The American Academy of Pediatrics (AAP) has developed this tool to aid in the implementation of oral health risk assessment during health supervision visits. This tool has been subsequently reviewed and endorsed by the National Interprofessional Initiative on Oral Health. Instructions for Use This tool is intended for documenting caries risk of the child, however, two risk factors are based on the mother or primary caregiver’s oral health. All other factors and findings should be documented based on the child.

The child is at an absolute high risk for caries if any risk factors or clinical findings, marked with a a sign, are documented yes. In the absence of a risk factors or clinical findings, the clinician may determine the child is at high risk of caries based on one or more positive responses to other risk factors or clinical findings. Answering yes to protective factors should be taken into account with risk factors/clinical findings in determining low versus high risk.

Patient Name:____________________________________ Date of Birth:___________________ Date:___________________ Visit: n 6 month n 9 month n 12 month n 15 month n 18 month n 24 month n 30 month n 3 year n 4 year n 5 year n 6 year n ___________________ Other

RISK FACTORS

a Mother or primary caregiver had active decay in the past 12 months n Yes n No

• Mother or primary caregiver doesnot have a dentistn Yes n No

• Continual bottle/sippy cup usewith fluid other than water n Yes n No

• Frequent snackingn Yes n No

• Special health care needsn Yes n No

• Medicaid eligiblen Yes n No

PROTECTIVE FACTORS

• Existing dental homen Yes n No

• Drinks fluoridated water or takesfluoride supplementsn Yes n No

• Fluoride varnish in the last6 monthsn Yes n No

• Has teeth brushed twice daily n Yes n No

CLINICAL FINDINGS

a White spots or visible decalcifications in the past 12 monthsn Yes n No

a

a Obvious decay n Yes n NoRestorations (fillings) present n Yes n No

• Visible plaque accumulationn Yes n No

• Gingivitis (swollen/bleeding gums)n Yes n No

• Teeth presentn Yes n No

• Healthy teethn Yes n No

ASSESSMENT/PLAN

Caries Risk: n n

n

n

n

n

n

n

n

n

n

n

n

Low High

Completed: Anticipatory Guidance Fluoride Varnish

Dental Referral

Self Management Goals: Regular dental visits Dental treatment for parentsBrush twice daily Use fluoride toothpaste

Wean off bottle Less/No juice Only water in sippy cup Drink tap water

n

n

n

n

Healthy snacks Less/No junk food or candy No soda Xylitol

Treatment of High Risk Children If appropriate, high-risk children should receive professionally applied fluoride varnish and have their teeth brushed twice daily with an age-appropriate amount of fluoridated toothpaste. Referral to a pediatric dentist or a dentist comfortable caring for children should be made with follow-up to ensure that the child is being cared for in the dental home. Adapted from Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Featherstone JD. Pediatric dental care: prevention and management protocols based on caries risk assessment. J Calif Dent Assoc. 2010;38(10):746–761; American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics. 2003; 122(6):1387–1394; and American Academy of Pediatrics Section of Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5):1113–1116. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright © 2011 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes.

Oral Health Risk Assessment Tool Guidance Timing of Risk Assessment The Bright Futures/AAP “Recommendations for Preventive Pediatric Health Care,” (ie, Periodicity Schedule) recommends all children receive a risk assessment at the 6- and 9-month visits. For the 12-, 18-, 24-, 30-month, and the 3- and 6-year visits, risk assessment should continue if a dental home has not been established. View the Bright Futures/AAP Periodicity Schedule—http://brightfutures. aap.org/clinical_practice.html.

Risk Factors a Maternal Oral Health

Studies have shown that children with mothers or primary caregivers who have had active decay in the past 12 months are at greater risk to develop caries. This child is high risk.

Maternal Access to Dental Care Studies have shown that children with mothers or primary caregivers who do not have a regular source of dental care are at a greater risk to develop caries. A follow-up question may be if the child has a dentist.

Continual Bottle/Sippy Cup Use Children who drink juice, soda, and other liquids that are not water, from a bottle or sippy cup continually throughout the day or at night are at an increased risk of caries. The frequent intake of sugar does not allow for the acid it produces to be neutralized or washed away by saliva. Parents of children with this risk factor need to be counseled on how to reduce the frequency of sugar-containing beverages in the child’s diet.

Frequent Snacking Children who snack frequently are at an increased risk of caries. The frequent intake of sugar/refined carbohydrates does not allow for the acid it produces to be neutralized or washed away by saliva. Parents of children with this risk factor need to be counseled on how to reduce frequent snacking and choose healthy snacks such as cheese, vegetables, and fruit.

Special Health Care Needs Children with special health care needs are at an increased risk for caries due to their diet, xerostomia (dryness of the mouth, sometimes due to asthma or allergy medication use), difficulty performing oral hygiene, seizures, gastroesophageal reflux disease and vomiting, attention deficit hyperactivity disorder, and gingival hyperplasia or overcrowding of teeth. Premature babies also may experience enamel hypoplasia.

Protective Factors Dental Home According to the American Academy of Pediatric Dentistry (AAPD), the dental home is oral health care for the child that is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist. The AAP and the AAPD recommend that a dental home be established by age 1. Communication between the dental and medical homes should be ongoing to appropriately coordinate care for the child. If a dental home is not available, the primary care clinician should continue to do oral health risk assessment at every well-child visit.

Fluoridated Water/Supplements Drinking fluoridated water provides a child with systemic and topical fluoride exposure, a proven caries reduction intervention. Fluoride supplements may be prescribed by the primary care clinician or dentist if needed. View fluoride resources on the Oral Health Practice Tools Web Page http://aap.org/oralhealth/PracticeTools.html.

Fluoride Varnish in the Last 6 Months Applying fluoride varnish provides a child with highly concentrated fluoride to protect against caries. Fluoride varnish may be professionally applied and is now recommended by the United States Preventive Services Task Force as a preventive service in the primary care setting for all children through age 5 http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation­summary/dental-caries-in-children-from-birth-through-age-5-years-screening. For online fluoride varnish training, access the Caries Risk Assessment, Fluoride Varnish, and Counseling Module in the Smiles for Life National Oral Health Curriculum, www.smilesforlifeoralhealth.org.

Tooth Brushing and Oral Hygiene Primary care clinicians can reinforce good oral hygiene by teaching parents and children simple practices. Infants should have their mouths cleaned after feedings with a wet soft washcloth. Once teeth erupt it is recommended that children have their teeth brushed twice a day. For children under the age of 3 (until 3rd birthday) it is appropriate to recommend brushing with a smear (grain of rice amount) of fluoridated toothpaste twice per day. Children 3 years of age and older should use a pea-sized amount of fluoridated toothpaste twice a day. View the AAP Clinical Report on the use of fluoride in the primary care setting for more information http://pediatrics.aappublications.org/content/early/2014/08/19/peds.2014-1699.

Clinical Findings

a White Spots/Decalcifications This child is high risk. White spot decalcifications present—immediately place the child in the high-risk category.

a Obvious Decay This child is high risk. Obvious decay present—immediately place the child in the high-risk category.

a Restorations (Fillings) Present This child is high risk. Restorations (Fillings) present—immediately place the child in the high-risk category.

Visible Plaque Accumulation Plaque is the soft and sticky substance that accumulates on the teeth from food debris and bacteria. Primary care clinicians can teach parents how to remove plaque from the child’s teeth by brushing and flossing.

Gingivitis Gingivitis is the inflamation of the gums. Primary care clinicians can teach parents good oral hygiene skills to reduce the inflammation.

Healthy Teeth Children with healthy teeth have no signs of early childhood caries and no other clinical findings. They are also experiencing normal tooth and mouth development and spacing.

For more information about the AAP’s oral health activities email oralhealth@aap.org or visit www.aap.org/oralhealth.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright © 2011 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications made to this document and in no event shall the AAP be liable for any such changes.